NU804 Unit 10 DNP Implementation Summary Example

Six Units Live, Eleven Changes Logged, Forty-Two Patients: A Unit 10 Implementation Summary of an Insulin Discharge Bundle Before Final Analysis

[Student Name]

Purdue University Global

NU804: DNP Project II

Unit 10 Implementation Summary

[Instructor Name]

[Date]

The hospital, units, patients, changes and data are composite and illustrative; the frameworks and guidance cited are real.

What Went Live, and When

The bundle went live on 4 West and 3 West in project week one, on cardiac step-down and the surgical unit in week six and on oncology and the renal-transplant unit in week 13, once the daily-call safeguard for steroid tapers was in place. The orthopedic and observation units are scheduled for week 19, in NU806. By the end of week 16, 42 patients had gone home on new insulin from the six live units.

Fidelity

Delivery of all five parts rose from 60 percent in month one to 75 percent in month three and 79 percent in the first half of month four, against a target of 85 percent. By component over the whole period, the supervised injection on the pen going home reached 38 of 42 patients, the plan 41, the pen by the first insulin day 32, contact by day three 39 and acceptance of a class or virtual class seat 16. Since the virtual class began in week 14, five of the eight patients offered it accepted.

Carroll et al. (2007) distinguish adherence from the moderators that influence it, including the quality of delivery. Adherence is close to target for the parts nurses control. Quality of delivery needed attention: the plan-accuracy near miss in week nine showed that a plan can be present and wrong, and an audit item for plan accuracy now catches that. No plan errors have been found in the 19 plans audited since.

The bundle that will be evaluated in NU806 is not the bundle in the proposal; it is the proposal plus eleven dated changes.

The Change Log

Each entry in the log carries a date, notes whether the change was foreseen or forced by events, names who chose it and says whether the core functions survived it, drawing on the reporting elements of Wiltsey Stirman et al. (2019). All eleven are fidelity-consistent.

1. Week 4: inpatient pharmacy supplies the home pen on Saturdays and Sundays, made permanent in week 11.

2. Week 5: pen stations added to night and weekend huddles.

3. Week 6: training video and pocket card for agency nurses.

4. Week 7: supervised dose moved to the evening before an expected morning discharge, agreed with the hospitalists.

5. Week 9: daily list of new insulin starters to the pharmacist for early prior authorization.

6. Week 9: plans generated only after the last medication reconciliation, with doses checked aloud.

7. Week 9: emergency contact called after a missed reply and a missed call.

8. Week 10: phone follow-up through an interpreter for Marshallese speakers until translated texts were ready in week 13.

9. Week 12: a correction calculation added to teach-back for patients sent home with a correction scale, and the scale reprinted as plain statements.

10. Week 13: daily educator or resource nurse calls for five days for oncology patients whose steroid dose falls by half within a week.

11. Week 14: a weekly virtual diabetes class.

What the Changes Have in Common

Read together, the eleven changes fall into three groups. Five closed gaps in reach, for weekend, night, agency, Marshallese-speaking and unreachable patients. Four protected the quality of a part already being delivered, from plan accuracy to the correction calculation. Two added support where risk was highest, for oncology patients on falling steroid doses and for patients who could not travel to the class. None removed or weakened a core function. The pattern matters for the evaluation, because most changes began between weeks four and fourteen, so the later months on the first units reflect a more complete bundle than the early ones did.

Interim Results

Outcome. Thirty-day follow-up is complete for 29 patients; two returned with a glucose problem, about 7 percent. The baseline for these units was about 14 percent. Two returns in 29 is far too few to draw a conclusion, and the final analysis will need each unit's full follow-up.

Balancing measures. Discharges were no slower than before the bundle, with the median order-to-departure time five minutes shorter than at baseline. Nurse time on follow-up averaged 1.6 hours a week. No patient has come back with a low, so the stopping rule has never been invoked.

Equity. Of 12 Medicaid or uninsured patients, eight received all five parts, against 24 of 30 others. The gap narrowed after week nine, when early prior authorization began.

Unexpected finding. A third of patients who replied to the day-one text were unsure of their dose, almost all of them on correction scales. Teaching was changed, and the question of simpler discharge regimens was taken to the hospitalists, who are reviewing their discharge order set.

What NU806 Will Analyze

The final analysis will follow the plan approved in NU802. For each unit, returns in the year before its start will be compared with returns after, combined across units, and reported as a difference with its interval. Run charts by unit will be annotated with go-live dates and with the eleven changes, so that movement can be read against what happened when. Process and balancing measures will be reported in full, and every measure will be broken down by insurance, by age band and by how far patients live from the hospital, printing a rate only once a group holds 20 patients. Under SQUIRE 2.0, the report must show readers the intervention as it was actually delivered, changes included, and not only as it was planned (Ogrinc et al., 2016).

Because units started at different times, the latest units will have short follow-up. The analysis will therefore present results for the first four units, which will have at least six months of data, as the main finding, with the last four reported descriptively.

What Remains for NU806

The orthopedic and observation units go live in week 19. Case management, which arranges follow-up, has not yet been engaged as a partner and will be in the first weeks of NU806. A second person is being trained on each audit so that measurement does not depend on the student. The NU712 sustainability plan will be updated with the owners confirmed during implementation.

Conclusion

Six of eight units are live, 42 patients have gone home with the bundle and delivery of every part has risen toward its target through eleven logged changes, all consistent with the bundle's core. Early outcome figures are encouraging but far too small to judge. NU806 will analyze the complete data against a complete record of what was delivered and when.

References

Carroll, C., Patterson, M., Wood, S., Booth, A., Rick, J., & Balain, S. (2007). A conceptual framework for implementation fidelity. Implementation Science, 2, 40. https://doi.org/10.1186/1748-5908-2-40

Ogrinc, G., Davies, L., Goodman, D., Batalden, P., Davidoff, F., & Stevens, D. (2016). SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised publication guidelines from a detailed consensus process. BMJ Quality & Safety, 25(12), 986-992. https://doi.org/10.1136/bmjqs-2015-004411

Wiltsey Stirman, S., Baumann, A. A., & Miller, C. J. (2019). The FRAME: An expanded framework for reporting adaptations and modifications to evidence-based interventions. Implementation Science, 14, 58. https://doi.org/10.1186/s13012-019-0898-y